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RCN Policy Unit Policy Briefing 06/2009

The Assistant Practitioner RoleA Policy Discussion Paper

April 2009

Royal College of Nursing Policy Unit – Room 209 20 Cavendish Square London W1G 0RN

Telephone Fax Email

020 7647 3754 020 7647 3498 policycontacts@rcn.org.uk

Introduction This document considers some of the key policy issues regarding the emergence of the role of the assistant practitioner in health care. They are the:

• remit and purpose of the role • reasons for the introduction of this role • role in the wider health care workforce context including workforce numbers,

nursing workload and the deployment of registered nurses. The nursing profession must hold a robust debate on all the above because the assistant practitioner role must be linked to a vision for both the future configuration of the nursing workforce, and the future function and contribution of nursing to health care within that. Some of the material and inspiration behind this document has been taken from an RCN policy event held on October 6th 2008 entitled The Future Nurse Workforce: What Should the Assistant Nurse Look Like? This event was deliberately premised on the basis that the assistant practitioner role was here to stay and assistant practitioner numbers would increase. The debate therefore centred on how the nursing workforce should be recast, and what needed to happen to ensure this, rather than if it should be. Four presentations were made as follows:

• The Future Nursing Workforce? by Professor James Buchan, Queen Margaret University, Edinburgh

• Future Nursing Roles and Careers by Professor Dame Jill Macleod Clark, University of Southampton

• A Case Study from the Acute NHS Sector by Louise Boden, Chief Nurse, University College London Hospitals NHS Foundation Trust

• Community Children’s Support Worker Role in the Community Setting by Joan Myers, Nurse Consultant, Islington NHS Primary Care Trust

The power point slides from these presentations are reproduced in Appendix 1 and we are grateful for the contribution of the speakers to this paper.

The Policy and Workforce Context There are a number of drivers for the introduction of the role of assistant practitioners into the health care workforce. These include:

• Current and predicted fall in the numbers of registered health care professionals and the need to develop ‘assistants’ to the professions

• Recruitment and retention to the health care workforce, and to the health care professions from the wider workforce, with clear career pathways and developmental opportunities

• Costs of health care, skill mix , efficiency and productivity

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• Development of careers that follow the patient health care journey and health care needs, rather than careers based on care settings or traditional professional boundaries

In 2008 the RCN commissioned Professor James Buchan to undertake predictive workforce modelling for registered nurse numbers under different sets of assumptions related to pre registration nurse education, and to registered nurse recruitment and retention (Buchan 2008). He identified three different scenarios, each with a range of predicted percentage change in registered nurse numbers:

• Steady state i.e. little difference to current drivers and levers (range = increase of 4.6% to decrease of 11.6%)

• Low intake i.e. less newly qualified nurses, less international recruitment, poor retention (range = increase of 3.7% to decrease of 18.5%)

• Retirement policy variations i.e. impacts of decisions re retirement, both increases and decreases in age of retirement (range = increase of 9.7% to decrease of 7.7%)

Buchan concludes: “The results highlight just how vulnerable the size of the NHS registered nursing workforce is to the impact and mix of possible policy changes, and also underlines the challenge of even maintaining the current size of the workforce in the future.” (p19) He also states that his modelling calculations1 are based on the workforce supply side of the workforce equation, and that workforce demand levers, such as an increase in long term chronic conditions in the population, will also have an impact regarding the size of the workforce. But also in terms of the skill mix and allocation of roles within the total workforce. Indeed the assistant practitioner role is already developing across the UK in response to demand side changes, albeit at different rates and in different ways. To summarise the size of the nursing workforce is dependant on future policy decisions about health care provision and the workforce to deliver this. Professor Dame Jill McCleod Clarks presentation (see Appendix 1) brings the above into sharp focus and puts forward a scenario of “escalating demand for nursing skills” given the correlation between an increasingly ageing population and a rise in long term, chronic conditions (which will pull on nursing skills in particular). McCleod Clark’s presentation gives a rough estimate regarding workforce demand AND workforce supply equations: “Demand for nursing intervention increases by 50% by 2020 to support those with long term conditions = 50% growth in registered nurses to sustain current shape of workforce (would mean recruit every 18 year old!) OR Change the shape of the workforce e.g. slowly reduce registered nurse numbers over time and incrementally increase ‘nursing assistant/assistant nurse’ numbers” (Macleod Clarke, 2008, in Appendix 1 Future Nursing Roles and Careers)

1 Which were undertaken before the current economic climate had taken hold

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Macleod Clark concludes that the only sustainable way forward for the nursing profession is to positively embrace change for the shape of a future nursing workforce, acknowledge there will be fewer registered nurses and not enough to meet all health care needs and demands, and actively shape nursing roles and career pathways from health care assistants to advanced nursing practice to take account of this. This will include the need for a substantial number of assistant practitioners at level 4 of the National Career Framework. She also points out that developing roles at the assistant practitioner level is extremely important in terms of bringing people into the registered nursing profession, and maintaining a wide entry gate to an all graduate pre registration nurse education programme (assistant practitioners2 at level 4 should have attained a foundation degree in health care which will be accredited towards a reduction in the length of the pre registration nurse education programme). However there is a more negative lever for the introduction of the assistant practitioner role which stems from control of health care costs, as the nursing workforce is a major item of NHS expenditure and therefore always a target for cost containment. There may be attempts to increase the number of assistant practitioners at AfC band 4 as a cost cutting measure, rather than as a response to workforce pressures or to match patient needs, especially in the light of the current economic downturn. The nursing profession must consider this imperative very carefully in the light of the impact of registered nurses on patient outcomes and quality care (RCN 2006, RCN 2007a), productivity and the appropriate deployment of registered nurses, role boundaries, competencies and accountability, and patient and public protection (RCN 2007b). The above leads on to a further question for the assistant practitioner role regarding whether it can (or should be) an opportunity to develop new ways of working allied to patient care pathways rather than traditional professional boundaries or care settings such as hospital and community. This was one of the original underpinnings for development of this role. The two case studies that were presented at the RCN policy event (see Appendix 1) by Louise Boden and Joan Myers outline the different scenarios and contexts regarding this. Louise Boden, Chief Nurse at University College London Hospitals NHS Foundation Trust (UCLH NHS FT) describes the context of a large acute teaching hospital in London and :

• Competitive recruitment and retention for NHS staff in London, especially the health care support workforce

• The need to encourage and develop a loyal, stable support workforce on a trust wide basis

• The need to maintain a high level of skill at ward level because of the high and complex level of in patient acuity

The solution for UCLH NHS FT was to work with ward sisters and charge nurses to develop health care assistants (HCAs) within their ward teams over a two year period accompanied by a higher education programme that led to foundation degree level. Following successful completion of this they were then integrated back into their ward team at band AfC 4 and entitled ‘nursing assistant practitioners’. The UCLH NHS FT

2 Applies to England

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model is thus about developing assistants to nursing from the existent health care support workforce within each ward team. In contrast the presentation by Joan Myers’ describes a different type of model whereby support workers employed in Islington NHS Primary Care Trust (who are titled ‘community children’s support worker’) work across nursing, therapy, social care and education agencies to provide integrated care to children with complex long term care needs. This model is about care in a community based setting that spans professional boundaries and agencies. Both models have merit but a key question is how advanced support worker roles such as both of these fit into the spectrum of the nursing family?

The Nursing Family The term ‘nursing family’ was coined in the RCN publication The Future Nurse: The RCN Vision Explained (RCN 2004) to denote an inclusive model of the nursing workforce within which nursing care is delivered by nursing teams that encompass a continuum of roles and functions from HCAs to nurses at advanced and specialist levels of practice. The term is therefore a positive acknowledgement by the professional trade union for nursing of the importance of the nursing contribution made by HCAs. There has been an unprecedented increase in the numbers of the health care support workforce, numbers having more than doubled since 1997 in England (Buchan and Seecombe 2006). However the term ‘health care support worker’ covers a myriad of roles and functions and it is not clear where, or in what way, the expansion of numbers has occurred. That said within nursing the support workforce now delivers a substantial proportion of essential nursing care. The role has also expanded to take on clinical tasks such as wound care, screening, venepuncture and so on, although the extent to which this has taken place is unclear (Knibb 2006). However there is still considerable confusion amongst registered nurses and support workers about role boundaries and what is acceptable or appropriate, concepts of accountability and responsibility, and the principles and practice of delegation of work. For example the report on the introduction of the assistant practitioner role in Manchester (Benson 2004) highlighted that professionals were sometimes unclear as to the tasks assistant practitioners could carry out and often assistant practitioners were not enabled to practice at the level they were capable of because of this lack of understanding. A number of factors appear to underpin this:

• The way in which the assistant practitioner role has been introduced into the local workforce

• Lack of clarity about how the role is (or could be) aligned to the nursing profession and what its’ key contribution is.

• Related to the above lack of ownership and responsibility by the nursing profession for the work and values base of the assistant practitioner role

• Above compounded by different regulatory bases of registered (regulated) nurses vis the non regulated support workforce

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Conclusion The RCN current position on the contribution of assistant practitioners to nursing is not one of opposition, and the RCN recognises the value of this role for patients and the nursing team. However we would become concerned if the assistant practitioner role were to be introduced merely as a means of reducing the costs of the registered nursing workforce (rather than to enhance patient care and the patient experience, and/or improve the career development of the support workforce). The key issues for debate concern:

• Current and future demands for health care and how to meet these appropriately and effectively

• Policy decisions about the size of the health care workforce, including how health care is delivered and by whom, coupled with the possibility of a decrease in numbers of registered nurses.

These must be debated by the nursing profession as a matter of urgency in order to influence the direction of travel. RCN Congress 2009 provides one opportunity for this to take place.

References Benson, L (2004) Delivering the Workforce: Evaluation of the Introduction of Assistant Practitioners in 14 Pilot Sites in Greater Manchester Manchester Centre for Health Care Management, University of Manchester, September Buchan J (2008) Nursing Futures, Future Nurses RCN: London www.rcn.org.uk/policy Buchan J and Seecombe I (2006) From Boom to Bust? The UK Nursing Labour Market Review 2005 to 2006 RCN: London ‘RCN General Secretary Issues Renewed Call to Regulate Health Care Assistants’ Nursing Times, 3rd March 2009 Knibb W (2006) The Contribution of Assistants to Nursing: Report for the RCN RCN: London www.rcn.org.uk/policy MacLeod Clarke J (2007) Ensuring A Fit For Purpose Future Nursing Workforce: A Policy Discussion Paper

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RCN: London www.rcn.org.uk/policy RCN (2004) The Future Nurse: The RCN Vision Explained RCN: London www.rcn.org.uk/policy RCN (2006) Setting Appropriate Ward Nurse Staffing Levels in NHS Acute Trusts RCN: London www.rcn.org.uk/policy RCN (2007a) Untapped Potential: A Survey of RCN Members Working in Mental Health RCN: London www.rcn.org.uk/policy RCN (2007b) The Regulation of Health Care Support Workers RCN: London www.rcn.org.uk/policy RCN (2009) Breaking Down Barriers, Driving Up Standards: The Role of the Ward Sister and Charge Nurse RCN: London www.rcn.org.uk/policy Sines, D and Naish, J (2008) Funding Nursing Education: A Policy Discussion Paper RCN: London www.rcn.org.uk/policy

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Appendix 1 Presentations from the RCN Policy Event October 6th 2009 ‘The Future Nursing Workforce: What Should the Assistant Nurse Look Like?’ The Future Nursing Workforce Professor James Buchan, Queen Margaret University, Edinburgh

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Future Nursing Roles and Careers, Professor Dame Jill McCleod Clarke, University of Southampton

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A Case Study from the Acute NHS Sector Louise Boden, Chief Nurse,

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University College London Hospitals NHS Foundation Trust

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Children’s Community Support Worker in Community Services Joan Myers - Nurse Consultant Islington NHS Primary Care Trust

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